Basic Information
Provider Information
NPI: 1609166545
EntityType: 2
ReplacementNPI:  
OrganizationName: RYAN C PETERSON MD INC
LastName:  
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Mailing Information
Address1: PO BOX 7001
Address2:  
City: TARZANA
State: CA
PostalCode: 913577001
CountryCode: US
TelephoneNumber: 8188887815
FaxNumber: 8187151722
Practice Location
Address1: 3209 HILLOCK DR
Address2:  
City: LOS ANGELES
State: CA
PostalCode: 900681427
CountryCode: US
TelephoneNumber: 3102663774
FaxNumber: 3233807420
Other Information
ProviderEnumerationDate: 04/12/2011
LastUpdateDate: 02/10/2020
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: PETERSON
AuthorizedOfficialFirstName: RYAN
AuthorizedOfficialMiddleName: C
AuthorizedOfficialTitleorPosition: DIRECT OWNER
AuthorizedOfficialTelephone: 3102663774
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate: 02/10/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207LP2900XA103097CAY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine

No ID Information.


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